HOWARD J.CURZER

ABSTRACT. Care is widely thought to be a role virtue for health care professionals (HCPs). It is thought that in their professional capacity, HCPs should not only take care of their patients, but should also care for their patients. I argue against this thesis. First I show that the character trait of care causes serious problems both for caring HCPs and for cared-for patients. Then I show that benevolence plus caring action causes fewer and less serious problems. My surprising conclusion is that care is a vice rather than a virtue for HCPs. In their professional capacity HCPs should not care for their patients. Instead HCPs should be benevolent and act in a caring manner toward their patients. Key Words: care, ethics, virtue It is quite possible that the best soldiers may not be courageous.

Aristotle INTRODUCTION lama very good man, but a very bad wizard.

The Wizard of Oz

This paper focuses on a point at which three of the most fashionable recent movements in ethics (virtue ethics, medical ethics, feminist ethics) intersect. There are some moral rules which people generally should obey (Do not kill; do not steal; etc.)- But different rules apply to people playing certain roles within the context of certain practices. (Soldiers generally should obey orders given by their commanding officers, but civilians have no such duty; parents generally

Howard Curzer, Philosophy Department, Texas Tech University, Lubbock, Texas 79409-3092, U.S.A. The Journal of Medicine and Philosophy 18: 51-69,1993. © 1993 Kluwer Academic Publishers. Printed in the Netherlands.

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should try to save their own children from a burning house before they try to save other children; etc..) The set of rules which applies to people playing certain roles is sometimes called a role morality. Role morality can be approached via virtue ethics, too. There are some character traits which, taken together, make someone a good person. A person lacking these virtues is morally deficient qua person. I shall call these general virtues. To be good at a role (to be a good lawyer or a good parent, for example), requires a collection of character traits which may be somewhat different from the general virtues. I shall call these character traits role virtues. I shall say with deliberate vagueness that role virtues are character traits which help the person achieve the goal(s) of the role. The constellation of virtues of a particular role is not always the same as the constellation of general virtues. To be good at a role might require all of the general virtues plus other character traits. Florence Nightingale suggests that this is true of nursing when she says that "A woman cannot be a good and intelligent nurse without being a good and intelligent woman" (Benjamin and Curtis, 1985, p. 257). However, this is not true for all roles. Some role virtues might not be general virtues and some general virtues might not be role virtues. Indeed, role virtues might be general vices ai d vice verse. The competitiveness that makes people good businessmen might make them bad people, for example, and the general virtue of benevolence might be a marketplace vice. There are further complexities. A character trait may occupy different places in the constellations of general virtues and role virtues. Courage, for example, has a higher priority as a military virtue than as a general virtue. Moreover, role virtues are often narrower than general virtues of the same name. For example, military courage, unlike general courage, is predominantly courage in battle. Since roles are embedded in practices and associated with institutions, role virtues are sometimes relative to practices and institutions. The virtues of a teacher in a large state university, for example, differ significantly from the virtues of a teacher in a rural, one room elementary school house.1 The practice with which I shall be concerned is medicine of the 1990's in major medical centers of industrialized countries. This is approximately the practice Veatch (1983, p. 188) calls 'stranger medicine' because it is medicine practiced among people who are essentially strangers. I do not think that what I have to say can be applied in any straightforward way to third world medicine, 19th

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century American medicine, or small town modern medicine, for example.2

The first step in approaching medical ethics from the perspective of virtue is to ask, "What are the role virtues of physicians, nurses, and other health care professionals (HCPs)?" Feminism has prompted a partial answer to this question. Some feminists have recently claimed that care is a virtue which has been somewhat neglected, perhaps because it has been thought to be a feminine virtue (Gilligan, 1982; Noddings, 1984). In particular, the following thesis has been advanced. (A) Care is a role virtue for HCPs (Fry, 1989, p. 99; Pellegrino, 1987, p. 22). A good HCP must have the character trait of care. The word 'care' is used in a variety of ways. Among other things 'care' might mean 'minister to' (take care of the sick), 'to take an interest in' (care about freedom), or 'to have a liking for' (care for chocolate). Of course, 'care' in thesis (A) does not mean merely 'minister to'. If thesis (A) is to be a non-trivial claim, then the character trait of care must include caring about as well as taking care of. I can take care of someone I do not care about, perhaps even someone I despise. HCPs should not only behave in certain ways toward patients, but HCPs should also care about patients. Nor can 'care' in thesis (A) mean merely 'take an interest in'. Heidegger uses the term 'care' roughly this way. For Heidegger 'care' refers to a morally neutral stance all people constantly have toward all sorts of things (Heidegger, 1962). In thesis (A), however, the term 'care' refers to a morally positive relationship with people and perhaps animals. Thesis (A), moreover, presupposes that some people are more caring than others and some are uncaring. Frankena's use of the term 'care' meets these conditions. He defines care as non-indifference or respect for persons (Frankena, 1983, p. 71-75)? But one can be dispassionately non-indifferent. One can take an interest in people without liking them. One can act in ways which respect rather than violate the autonomy of people without wishing them well let alone being emotionally attached to them. But this cannot be what 'care' means in thesis

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I hate definitions. Benjamin Disraeli

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(A), and this is not what the feminists mean by 'care'. If 'caring' meant merely respecting people's personhood, then there would be no different voice. The ethics of care would be no different from the ethics of justice. Feminists would merely by Kantians, and thesis (A) would be trivial. Note that respect for persons is not the same as benevolence. A benevolent person not only respects the autonomy of others, but also wishes them well and tries to help them even on certain occasions when he or she has no duty to do so (Wallace, 1978, pp. 128-131). Note also that benevolent people need not 'have a liking for' the objects of their benevolence. It is perfectly possible to be benevolent even toward people one dislikes. As the feminists, the advocates of thesis (A), and I use the term, 'care' means 'have a liking for' a person, caring for that person. Care, unlike benevolence, involves emotional attachment. But what sort or level of emotional attachment?4 Emotional attachments toward other people can be arranged roughly by degree ranging from dispassionateness through the attachment typically felt for mere acquaintances, the attachments typical of mild and close friendships, all the way to the attachment typical of love. As the feminists, the advocates of thesis (A), and I use the term, 'care' involves not just the mild emotional attachment that we feel for the acquaintance, but considerably more emotional attachment. Care involves at least as much emotional attachment as is typical of mild friendship.5 Roughly speaking, the number of objects of attachment is inversely proportional to the degree of attachment. A person with the general virtue of care typically cares a lot for a small circle of intimate friends and family, somewhat less for a larger circle of ordinary friends, and does not care for everyone else. (The caring person may be non-indifferent or even benevolent toward everyone else since dispassionate non-indifference and even dispassionate benevolence is possible, but the caring person is not emotionally attached to everyone else.) The objects of the medical virtue of care are, however, a different group of people from the objects of the general virtue of care. Clearly, if care is a virtue for HCPs, then the objects of care for HCPs are predominately the patients. Therefore, if care is a role virtue for HCPs, then in their professional capacity HCPs should not only minister to (take care of) and take an interest in (care about) their patients, but they should

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also have a liking for (care for) their patients. And not just any degree of liking. Thesis (A) implies that HCPs should be significantly emotionally attached to their patients.

Jane Austen

'Caring' is a term so loaded with positive connotations that to criticize anything related to it is risky. No one wants to be perceived as 'against caring' so I must proceed cautiously. Of course, I think that caring is a general virtue. Of course, I think that caring is a role virtue for some roles (e.g. parenting). Nevertheless, I think that thesis (A) is false. Care is not a role virtue for HCPs. Indeed, it is a vice. In their professional capacity, doctors, nurses, and other HCPs should not care for their patients.6 This is not the completely counterintuitive claim that HCPs should be uncaring brutes indifferent to the fate of their patients. Rather my claim is that they should not become significantly emotionally attached to their patients. Suppose, for example, that Anne is a doctor who does everything a doctor is supposed to do in the right way, at the right time, etc., except that she does not care for her patients. Her diagnoses are accurate. Her therapies are effective. Her manner is warm and friendly. She communicates well with her patients. And so on. In general, Anne wants to improve the overall length and quality of life of her patients and acts effectively to do so. But she does not regret the suffering and death of her patients any more than she regrets the suffering and death of other people's patients because she is not significantly emotionally attached to her patients. It would be very strange to say that Anne is not a good doctor. Yet that is what we would have to say if (A) care is a role virtue for HCPs.7 I shall argue for my claim in two stages. First, I shall show that care causes serious problems both for caring HCPs and for cared for patients. Second, I shall argue that (Bl) benevolence is a role virtue for HCPs and suggest that (B2) benevolence disposes HCPs to perform caring acts (acts typically performed by caring people). My argument for (Bl) will consist in showing that benevolence causes fewer and less serious problems than care.

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General benevolence, but not general friendship, makes a man what he ought to be.

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Howard J. Curzer DRAWBACKS OF CARE She loves you. And you know that can't be bad.

Let me begin with a small but important point. Contrary to what is commonly believed, being cared for is not always intrinsically desirable.8 In any given case, whether being cared for is intrinsically desirable depends on various factors within the situation. Anyone who has been the object of unrequited love can testify that being cared for can be a burden as well as a good. As feminists have emphasized, it is not always desirable to be cared for solely because of one's appearance. Finally, like other human emotions, care can assume twisted forms which torment the cared for person. Some varieties of sadism, for example are really manifestations of care. The desirability of being cared for is a function of who is doing the caring, why one is cared for, and how the care is manifested. Moreover, even if the who, why, and how of caring are OK, being cared for can be an intrusive invasion of privacy. Some people may not want to become an object of significant emotional attachment by the members of a whole medical team overnight. It is not a great pleasure to bring pain to a friend.

Sophocles

Although caring usually benefits the person cared for in various ways, it has some straightforward, bad consequences, too. Caring makes some desirable actions more difficult and less frequent. Consider hurting someone for whom you care, causing intense physical pain. Consider communicating very bad news to someone for whom you care, causing intense mental anguish. Hurting patients and communicating very bad news to patients are things that HCPs frequently should do. They may be more reluctant to hurt patients for whom they care even when doing so is therapeutically indicated. They may be more reluctant to tell patients for whom they care very bad news even if the patients should know the truth. Similarly, caring usually makes it harder to withhold or withdraw treatment, deny patient's requests, etc. Yet these acts, too, are appropriate in some situations. Being cared for is, therefore, not always an unmitigated good.

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The Beatles

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57 / love you. You belong to me. Paul in Breakfast at Tiffany's

[the HCP] may relish a caring relationship and foster patient dependency to meet his or her own needs for caring, thus interfering with treatment goals that work toward patient autonomy and health.

Of course, all this is a long way from a demonstration that the disadvantages of being cared for outweigh the benefits. Indeed, what I have said so far suggests important ways in which care is beneficial. The cases where reluctance to hurt inspired by care saves patients from unnecessary pain probably far outnumber the cases where this reluctance deprives patients of painful, but overall beneficial therapy. So far I have merely shown that being cared for is not always purely good either intrinsically or instrumentally.9 Love your neighbor as you love yourself.

Jesus

The character trait of care involves emotional attachment to a person. We do not feel this attachment to others just because they are people. Instead, we feel it because of the particular people they are, because of particular facts about them. We care for others qua individual rather than qua person. Indeed, the injunction to care for patients often functions as a way of stressing that patients should be treated as individuals rather than mere numbers.

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Caring also makes some undesirable actions easier and more frequent. Consider deceiving someone for his or her own good. People are more willing to deceive paternalistically those for whom they care than strangers. The caring relationship serves as a sort of justification. Some people sometimes think that caring for someone entitles the caring person to some control over the life of the cared for person. The nurse who enters the room without knocking because she thinks herself entitled to a friend's liberties is a minor example. The doctor who prescribes a placebo for the patient's own good is a more serious example. In general, caring for a person seems to make paternalism easier and more frequent. Yet paternalism is seldom appropriate for HCPs. Morse et al. (1990, p. 11) mention another common way in which caring yields undesirable consequences.

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What would happen to me if I loved all of the children I said goodbye to?

Mary Poppins

One of the major problems facing HCPs is the problem of burnout. There are many causes of burnout, but one of them is surely getting significantly emotionally involved with patients, i.e. caring. Caring contributes to burnout in a variety of ways. First, the HCP can bring his or her patients' problems home only so long before giving up on the profession. People have only a

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Since care requires an emotional investment based on particular facts, since we care for people as individuals, HCPs cannot care equally for all patients. A patient may be difficult for me to care for because he or she reminds me of an old flame who jilted me, has a sour personality, or has irritating mannerisms and bad breath. A patient may be easy to care for because he or she shares interests with me, is physically attractive, or has a great repertoire of jokes. It would require a saint to care for some really disgusting patients. Unrepentant child molesters, serial killers, highly manipulative sadists, etc. get sick and become patients just like the rest of us. As Downie and Telfer (1980, p. 91) observe "[S]ome things are clearly not psychologically possible. A caring worker cannot be in love with all his clients. Nor can he even like them all." The character trait of care requires us to care for people as individuals rather than merely as persons, and this, in turn, implies that we care for people unequally and that there are some people for whom we do not care (Noddings, 1984, p. 18). Of course, this is not an objection to the general virtue of care, but it is an objection to the thesis that (A) care is a role virtue for HCPs. The fine talk of caring for patients as individuals conceals a nasty reality. To accept it is to endorse and encourage favoritism in health care. In practice, such talk encourages the HCP to take care of patients only insofar as the HCP likes the patient. The HCP, however, ought to be as impartial as possible toward patients. Note, moreover, that the patient's race, sex, and age are sometimes relevant to the ability of HCPs to care for the patient. Favoritism opens the door to even more unsavory practices such as racism, sexism, and ageism. These 'isms' have no place in the health care setting. Care is a problematic character trait for HCPs since it endorses and encourages these 'isms'.

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A doctor who treats himself has a fool for a patient and a quack for a doctor. Anonymous

Objectivity is a central virtue for every professional, especially for HCPs. Loss of objectivity decreases the accuracy of diagnosis, the

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limited tolerance for sharing sorrow and suffering. Emotional resources often get used up. Second, caring increases the vulnerability of the person who cares. To care for someone is to make an emotional investment which often becomes costly if the object of care dies, suffers, does not live up to expectations, rejects the care, recovers and departs, etc.. Caring people get burned. Third, not only the practice of caring, but the very ideal of caring causes burnout. Some HCPs feel guilty about their inability to care for all of their patients equally. This guilt contributes to burnout. Thus, care causes burnout through emotional exhaustion, vulnerability, and self-recrimination (Maslach, 1982, pp. 2-14). Burnout harms both HCPs and patients in direct and obvious ways. Burned out HCPs often suffer physical and psychological deterioration. Their patients, family, and friends also suffer. So do institutions and practices with which the burned out HCPs are associated. Emotional exhaustion leads people to quit. It thus exacerbates the shortage of HCPs (especially nurses), making the remaining staff more inadequate and overworked. Sometimes quitting is the lesser evil. Emotionally exhausted HCPs who remain often unconsciously adopt various counter-productive coping strategies to minimize their emotional investments in their patients. These strategies undermine the ability of the HCP to deliver health care while exacerbating the original problem. Vulnerability leads to negative assessments of patients. "They are all trolls". It leads to detached, callous attitudes and responses to patients. Moreover, vulnerable people tend to strike back indiscriminately. They sometimes blame and punish not just the ones they cared for but also others. They often adopt vindictive attitudes toward people, in general. Self-recrimination, like emotional exhaustion, often leads to counterproductive coping strategies. Negative attitudes toward oneself take the joy out of one's own life and undermine the health care delivery process. Thus, ironically, caring for people often leads to burnout which often leads to treating people in uncaring or even hateful ways.

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The logic underlying an ethic of care is a psychological logic of relationships which contrasts with the formal logic offairness that informs the justice approach.

Carol Gilligan

HCPs who care for their patients naturally tend to take their primary allegiance and duty to be toward their own patients rather than other people's patients or the community. Naturally, they try to get the best for their own patients. They tend to put their own patients first. This poses two problems in a situation of scarce resources. First, caring drives the cost of health care up. Second, caring impairs the ability of HCPs to allocate resources according to need. In other words, caring produces inefficiency and unfairness. Consider the following oversimplified situation. The best therapy (BT) for a certain disease (D) is new, scarce, and very expensive. The second best therapy (SBT) is much cheaper, but not much worse except in a few cases. If doctors each care for their own patients, then they will tend to prescribe BT for their patients when the cost of BT is covered by third party payers. This will cause insurance or tax rates to go up, and therefore will cost many people a great deal. Overall, the community would be better off if doctors would prescribe SBT although the patients with D would usually be slightly worse off.12

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correctness of treatment decisions, the success rate of procedures, etc.. In general, objectivity is necessary to provide the best medical care.10 Emotional ties to patients tend to compromise the objectivity of professionals. Other things being equal, the degree of objectivity about a patient is more or less inversely proportional to the degree of emotional attachment to the patient. Thus, doctors are warned not to treat themselves, their family members, or their friends as patients. They are too emotionally attached to self, family, and friends to be objective. Their caring prevents them from providing the best medical care to the ones for whom they care. Therefore, it seems bizarre to suggest that HCPs should care for their patients, for this implies that they should abandon their objectivity, compromise their professional judgment, and, in general, decline to provide their patient with the best medical care.11

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ALTERNATIVES TO CARE

To bear the unbearable sorrow the Man of La Mancha

It would be very odd if a character trait that led to burnout, bias, injustice, and inefficiency was a virtue. All of these drawbacks, however, do not, by themselves, show that care is a vice for HCPs. After all, in addition to these drawbacks, care has many obvious advantages which I have not mentioned. If all of the alternative character traits have worse drawbacks and/or fewer advantages, then care will turn out to be a virtue after all. So I must show that there is a better character trait for HCPs to have than care. One way out of the problems of favoritism, burnout, objectivity loss, etc. is to say that HCPs should combine something like care with something like professional distance. Maslach (1982, pp. 147-148), for example, recommends the attitude of 'detached concern'. This recommendation is ambiguous. It might mean that HCPs should adopt a watered down version of what I have been calling care. HCPs should have a positive emotional attachment to their patients, but that attachment should be much less than the emotional attachment associated with caring. If this is what 'detached concern' means, then Maslach's recommendation is not significantly different from my own. (See below.) However, Maslach's recommendation might be that HCPs should simply add a buffer of professional distance to undiluted care. HCPs should maintain a substantial emotional attachment to their patients, but somehow temper that attachment with detachment. If this is what 'detached concern' means, then it is not a viable or even intelligible recommendation. It is an oxymoron.

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If doctors each prescribed BT for their own patients, then the distribution of BT would be based on the access of physicians to BT rather than according to need, desert, etc.. So a few people who desperately need BT (because they are allergic to SBT, for example) will not get it because the supply of BT will be exhausted. If doctors did not care for their patients, these all-toocommon problems would arise less frequently. So these problems undermine the claim that care is a role virtue for HCPs.

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Like oil and water, detachment and concern do not mix. The recommended attitude is impossible to adopt because detachment and concern are incompatible.

My proposal replaces the thesis that (A) care is a role virtue for HCPs with the thesis that (Bl) benevolence is a role virtue for HCPs, and since patients are generally best helped by caring actions, that (B2) benevolence disposes HCPs to perform caring acts. Benevolent behavior in the health care context is caring behavior. So I am advocating a shift from an ethics of care, to an ethics of care behavior. My suggestion is that HCPs should act as if they cared for patients as individuals, but it is not necessary or even desirable for them really to care for patients. HCPs should act as if they are significantly emotionally attached, but in fact should involve their feelings relatively little. They should be no more emotionally attached to their own patients than to someone else's patients or to the proverbial man on the street. HCPs should do the things that a person who really cared would do in the way that such a person would do them.13 They should take special note of individual differences among patients, adopt an informal, friendly manner, take an interest in non-medical aspects of patients' lives, etc. (Downie and Telfer, 1980, p. 91). They should hug patients who need to be hugged. But they should not really care. OBJECTIONS TO MY PROPOSAL

A good tree does not produce decayed fruit any more than a decayed tree produces good fruit. Jesus

Someone might object to my proposal by claiming that HCPs cannot consistently provide caring actions without actually caring. This objection is not without force. It must be conceded that, other things being equal, a person who really cares for patients will be able to treat patients in a caring manner more consistently than a person who does not really care for patients.

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Hypocrisy is not generally a social sin, but a virtue. Miss Manners

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Yfhy Grumpy, you do care! Snow White

Another objection to my arguments is that they seem to imply that parents should not care for their children. Actually, however, my arguments do not really have this implication. Parents have many fewer children than HCPs have patients. And, of course, parents do not see their children rarely and only in institutional settings as HCPs see their patients. The dangers of favoritism, burnout, inefficiency, and unfairness are, therefore, much less for caring parents than for caring HCPs. The danger of objectivity loss is greater, but is compensated for by the fact that a parents have greater knowledge about their children than do HCPs about their patients. Thus, the drawbacks of care are much less for parents than for HCPs; so much so that the advantages of care outweigh the drawbacks for parents. Parents should care for their children although HCPs should not care for their patients. (Day-care workers seem to me to be a borderline case.) Men become gods by excess of virtue. Aristotle (NE VH1) But clearly the virtue we must study is human virtue. Aristotle (NE 113)

There is a sense in which courage is not a good character trait for an unjust person to have. It is better for an unjust person to be held back from robbery by cowardice than to go on to become a bold knave. Nevertheless, we call courage a virtue because it is a good character trait for a person with all of the other virtues to

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But other things are not equal. As I have mentioned above, caring HCPs are at higher risk of burnout, and burnout typically leads to treating patients in an uncaring manner. So although caring HCPs may act more caring at the beginning of their careers, benevolent but uncaring HCPs are more likely to act in a caring manner throughout the course of their careers. Moreover, caring for patients is by no means the dominant factor in the ability to treat patients in a caring manner. If getting HCPs to treat patients in a caring manner is the goal, then it would be much more effective to train HCPs in certain techniques than to urge HCPs to care for their patients.

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[Ivan llych] wished most of all... for someone to pity him as a sick child is pitied.

Leo Tolstoy

My proposal seems to be open to an objection which has bedeviled Kant's theory of moral worth. Sometimes what a person wants and needs is to be cared for. Mere caring words and actions springing from some other character trait such as dutifulness or even disinterested benevolence will not do. I shall not contest this claim here, though I do believe it is more controversial than some seem to think. Instead, I shall merely observe that it does not follow from the fact that patients have certain needs that it is the function of the HCP to meet these needs. After all, it is not the function of the HCP to meet all of the needs of the patient. To assume that providing emotional attachment to patients is part of the HCPs job description would beg the question of whether care is a medical virtue. Alienation appears not merely in the result but also in the process of production.

Karl Marx

My theses that (Bl) benevolence is a role virtue for HCPs, and that (B2) benevolence disposes HCPs to perform caring acts would

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have. Similarly, perhaps care is not a good character trait for HCPs who are susceptible to burnout, bias, objectivity loss, etc. to have. But people are all not equally prone to these things. If the ideal HCP is well defended against the dangers of care so that its advantages outweigh its disadvantages, then is not care a virtue for HCPs?14 As usual when doing virtue ethics we must have recourse to the notion of a range of normal character traits. HCPs who are not susceptible to burnout, bias, objectivity loss, etc. while practicing modern medicine in major medical centers are vanishingly rare. There may well be a few extraordinary individuals for whom care is overall beneficial. But a character trait which is only good for a moral saint or superman to have is not a virtue. Instead a virtue is a character trait which is good for a normal good person to have. As I have shown, the character trait of care is not good for a normal HCP to have, so care is not a virtue for HCPs.

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solve the problems of favoritism, burnout, objectivity loss, etc. Of course my proposal has its own drawbacks, (a) From the HCPs point of view, the HCPs would be required to fake it on a regular basis, to live a lie. The peril of burnout would be replaced with the evils of alienation, (b) From the patient's point of view, patients might believe that HCPs care for them even though the HCPs do not really care. The perils of favoritism and objectivity loss would be replaced by the evils of deception, (c) Finally, there is a risk that HCPs will accept my rebuttal of the thesis that (A) care is a role virtue for HCPs while rejecting (Bl) and (B2). Unscrupulous or incautious HCPs might use my arguments that HCPs should not care for their patients as rationalizations for acting in uncaring ways toward their patients. Now these are real dangers, but I do not think that they are very serious, (a) People who meet the public (e.g. salespeople) are often required to smile when they feel surly, be helpful to people they despise, etc.. This does not typically produce intolerable tension or psychic trauma. Nor is the performance of caring actions likely to cause HCPs to become confused whether they care for certain patients. (b) In our society caring acts are performed by a wide range of professionals and institutions. Customers and clients are well aware that these acts are often performed without attachment, that they are just part of the job. Indeed, people are often somewhat cynical about such acts. Patients will not leap to the conclusion that HCPs, whom they meet for relatively short blocks of time in professional contexts, care for them. HCPs will not typically deceive themselves or their patients by performing caring actions. In the relatively rare cases where there is a significant chance that patients might be misled by caring actions the HCPs may ward off misunderstandings by stating up front in a gentle way that they are not intending to befriend the patient, but are merely doing their jobs. (c) Finally, almost any doctrine can be intentionally or accidentally twisted into a rationalization for something repulsive. I can only emphasize that my thesis does not justify or excuse HCPs who act in uncaring ways. HCPs should perform caring acts for patients. They just should not care for patients.

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Howard J. Curzer CONCLUSION Money can't buy you love.

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Let us step back for a moment and look at the larger context. We have been discussing an aspect of the HCP/patient relationship. My suggestion is compatible with the consumerist, freemarket model of the HCP/patient relationship, but the thesis that (A) care is a role virtue for HCPs is not compatible with this model. According to the consumerist model it is unreasonable to expect the HCP to care for the patient for the same reason that it is unreasonable to expect the HCP to love the patient. Emotional attachment is not the sort of thing which can be bought and sold. Thesis (A) is compatible only with the paternalistic model, I think. So to advocate thesis (A) is indirectly to endorse the paternalistic model of the HCP/patient relationship. But the paternalistic model endorses some fairly unsavory practices. Thesis (A) is tarnished by the company it keeps. Another aspect of the larger context is the enormous recent change in the nature of the health care delivery system. Most people's health care needs used to be met by the old family doctor who was also a family friend. (Or at least this is what most people 'fondly remember'.) Qua friend the old family doctors cared for their patients. These solo practitioners have now been replaced by health care teams within health care institutions. The HCP no longer sees the patient frequently in a variety of different settings as part of an ongoing multifaceted relationship. Instead HCPs typically see their patients only rarely, only professionally, and only within an institutional setting. This change of the institutions and practices of health care exacerbates most of the drawbacks of care mentioned above and tips care over the edge from virtue to vice for HCPs. Expecting contemporary HCPs to care for their patients is as unreasonable as expecting love from a prostitute. In both cases the relationship seems intimate, but the exchange of money, the infrequency of contact, and the one-dimensionality of the relationship makes the relationship purely professional. Emotional attachment is incidental and destructive to the practice.

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NOTES 1

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I take no position here on whether general virtues are relative to practices and/or institutions. 2 The importance of this qualification was suggested to me by Kai Wong. 3 The title of my paper gets its maximum shock value when 'care' is understood in this sense. If the alternative to being a caring HCP is to be an uncaring, indifferent one, then of course HCPs should care for their patients. 4 A virtue is not merely a disposition to act in certain ways. It also involves having the right habits of passion, belief, desire, taste, and motive. To paraphrase Aristotle, a caring person, a person with the virtue of care, is a person who tends to form and maintain caring relationships with the right people, in the right way, with the right emotions, etc.. So we must ask "What are the right emotions and who are the right people?" 5 Of course this does not imply that caring relationships are friendships. Friendships are two-way relationships, but caring relationships need not be twoway. 6 This claim implies that being a good HCP is incompatible with being a good person (and parent) or that it is possible to possess the general virtue of caring (and the parental virtue of caring) without caring for patients. I believe the latter implication to be correct. 7 Of course my opponent might say that people such as Anne do not exist. I shall try indirectly to show that they do. 8 The belief that being cared for is intrinsically desirable is often coupled with some fairly wild claims about the wonderful consequences of the caring relationship. Jean Watson, for example, claims that "In a transpersonal caring relationship, a spiritual union occurs between the two person where both are capable of transcending self, time, space, and the life history of each other" (Watson, 1988, p. 66). Lenninger claims that "[T]here can be no effective cure without care" (Lenninger, 1985, p. 210). I shall not bother to debunk these wild claims. 9 Of course, this is true for 'being the objecf of most virtues as well as vices. So far I have merely tried to raise the question of whether care is an overall good. I have merely tried to show that the answer is not obvious. 10 It sometimes said that objectivity is somehow antithetical to treating a patient as an individual. The idea is that an objective, scientific approach involves subsuming patients under general laws, classifying patients together with others with similar diseases and situations. It tends to put patients into pigeon holes and ignores the individuating details among patients. A subjective approach, on the other hand, focuses on what is unique about each patient. It tends to pick up important facts which the objective approach misses. This is a mistake. What is actually going on here is that a sloppy objective approach is being contrasted with a careful objective approach. The former approach is called 'objective' and the latter approach is called 'subjective'. But there is nothing subjective about carefully seeking all of the details about each patient. Indeed, a truly subjective approach tends to miss things, for a subjective

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REFERENCES Benjamin, M. and Curtis, J.: 1985, 'Virtue and the practice of nursing', in E. Shelp (ed.), Virtue and Medicine, D. Reidel Publ. Co., Dordrecht, pp. 257-273. Downie, R. and Telfer, E.: 1980, Caring and Curing, Methuen and Co., London. Frankena, W.: 1983, 'Moral-point-of-view theories', in N. Bowie (ed.), Ethical Theory in the Last Quarter of the Twentieth Century, Hackett, Indianapolis, pp. 39-79. Fry, S.: 1989, The role of caring in a theory of nursing ethics', Hypatia, 4,88-103. Gilligan, C : 1982, In a Different Voice, Harvard University Press, Cambridge. Heidegger, M.: 1962, J. Macquarrie and E. Robinson (trans.), Being and Time, Harper & Row, New York. Lenninger, M.: 1985, 'Transcultural care diversity and university: A theory of nursing', Nursing and Health Care, 6, 209-212. Maslach, C: 1982, Burnout: The Cost of Caring, Prentice- Hall, Englewood Cliffs. Morse, J. et al.: 1990, 'Concepts of caring and caring as a concept', Advances in Nursing Science, 13,1-14. Noddings, N.: 1984, Caring, University of California Press, Berkeley. Pellegrino, E.: 1987, The caring ethic: The relation of physician to patienf, in A. Bishop and J. Scudder (ed.), Caring, Curing, Coping: Nurse, Physician, Patient Relationships, University of Alabama Press, Birmingham, pp. 8-30. Veatch, R.: 1983, The physician as stranger: The ethics of the anonymous patientphysician relationship', in E. Shelp (ed.), The Clinical Encounter: The Moral

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approach takes the biases of the investigator to be central guides of the investigation rather than obstacles to be overcome. 11 It might be argued that nurses are different from other professionals in that objectivity is not central to or even part of nursing. This is a dangerous line of argument for it undermines the claims of nursing to be a profession. But it is also mistaken. Clearly, nursing includes tasks such as watching for particular symptoms and general changes in the overall health of the patient, administration of medication, performing and assisting in the performance of procedures, transmission of information between patient and doctor, etc.. These are tasks for which objectivity is crucial. 12 In some cases the patients with D would be better off, too (perhaps because of economies of scale in the production of SBT). In these 'prisoner dilemmas' cases, if doctors each care for and prescribe BT for their own patients, the best interests of everyone, even the patients, are defeated. 13 Does this mean that benevolent, but uncaring doctors would prescribe BT rather than SBT for their patients? No. Unlike care, benevolence does not involve favoritism. Benevolent doctors will try to do what is best for all concerned rather than giving preference to the interests of their own patients. Thus, they will prescribe SBT. 14 This objection was suggested to me by Walter Schaller.

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Fabric of the Patient-Physician Relationship, D. Reidel Publ. Co., Dordrecht, pp. 187-207. Wallace, J.: 1978, Virtues and Vices, Cornell University Press, Ithaca. Watson, J.: 1988, Nursing: Human Science and Human Care, National League for Nursing, New York.